Provider Demographics
NPI:1295290625
Name:WARD, ANGELA LYNN
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYNN
Last Name:WARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 DINSMORE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34288-6844
Mailing Address - Country:US
Mailing Address - Phone:941-769-0810
Mailing Address - Fax:
Practice Address - Street 1:1141 DINSMORE ST
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288-6844
Practice Address - Country:US
Practice Address - Phone:941-769-0810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101669300261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101669300Medicaid